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Original Question

A 47 year old male comes to an outpatient clinic with a complaint of pain. Medical history High blood pressure two DVT thrombosis one in the left leg 10 years ago and one in the right like two years ago family history of cardiovascular disease and diabetes on Gwen muscular X, not relieve over-the-counter medication, such as ibuprofen Physical assessment Client has a wobbled gait a hunched over the shoulders and make facial grimaces while getting on the examination table. Client was reports mail tinnitus, and usually goes away on its own. Medications Furosemide 40 mg daily Omeprazole 20 mg daily Warfarin 3 mg daily Nursing notes 10 2XX 1700 The client reports increased joint and muscle pain on both legs of the body, especially in the lower back hands and risk. He also has been experiencing abdominal pain and heartburn for the past three months. The client works at loading dock and reports lifting heavy boxes daily to get through the day. The client has increased ibuprofen intake between 800 and1200 mg every 4 to 6 hours daily in the past four months. 1715 Assessed the clients musculoskeletal system by having the client perform several range of motion exercises. The client reports and increased pain to six out of 10 when pronating and supinating the wrist on both hands when rotating the spine. 1725 Contacted the provider by phone and gave report on assessment and range of motion findings 1745 Teaching plan created for the client 1800 Provider discuss the next steps with the client, rustic x-ray and CT scan ordered schedule the x-ray and CT scan and a follow up appointment for client to review the results with the provider 10/14 XX 0900 Obtain vital signs and review CT scan report CT scan of the abdomen shows changes to the mucosal membrane of the upper gastrointestinal track. The x-ray of the lumbar spine shows narrowed the alignment after collaborating with the provider. Based on these findings provided patient education for the client to take aspirin instead of ibuprofen and encourage a client to eat small mouse of food every hour, including cream and milk for the fat and calorie content. Encourage the client to review and implement physical and psychosocial lifestyle changes to include proper body mechanics and physical therapy exercises encourage bedrest when the client is not at work to preserve strength and to sleep in a semi final position. 11/12/XX 1030 The clan has returned to the clinic for a follow up visit. His gate has improved since his last visit and he states he is in good spirits. The pain and his joints have improved significantly since implementing proper body mechanics. When ask about the G.I. symptoms he states the pain in his abdomen gets better when he eats, but does come back occasionally he states he is having mild tinnitus regularly, though it has declined since his last visit he informed the nurse he has lost approximately 8 pounds since the last visit. Temp 98.4 Fahrenheit, which is 36.9 Celsius Heart rate 91 bpm Pulse 16 breaths per minute SPO2 99 on room air Blood pressure 128/63MMHG

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